Assesment of Recurrent Chest Infections

Assessment of the child with recurrent chest
infections
Jon Couriel
Respiratory Unit, Royal Liverpool Children’s Hospital, Liverpool, UK
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The child with recurrent chest infections presents the clinician with a difficult diag-
nostic challenge. Does the child have a simply-managed cause for their symptoms,
such as recurrent viral respiratory infections or asthma, or is there evidence of a
more serious underlying pathology, such as bronchiectasis? Many different disorders
present in this way, including cystic fibrosis, a range of immunodeficiency
syndromes, and congenital abnormalities of the respiratory tract. In some affected
children, lung damage follows a single severe pneumonia: in others it is the result
of inhalation of food or a foreign body.
The assessment of these children is demanding: it requires close attention to
the history and examination, and in selected cases, extensive investigations. Early
and accurate diagnosis is essential to ensure that optimal treatment is given and
to minimise the risk of progressive or irreversible lung damage.
The aim of this chapter is to examine the causes of recurrent chest infections
and to describe how this complex group of children should be assessed and
investigated.
Recurrent chest infections are a common reason for children to be seen

by their general practitioner (GP) or a paediatrician. Recurrent or
persistent cough may be the only symptom, but often there is also a
history of wheeze, breathlessness, sputum production or general ill-
health. A number of disorders can present with these features (Table 1).
Many of these children are simply having the repeated viral upper
respiratory tract infections that are a normal part of growing up. In
others, the symptoms are the first manifestations of asthma. But, in an
important minority there is a clear history of persistent or recurrent
episodes of pneumonia, or of chronic sputum production, indicating
more severe pathology.
Correspondence to:
The challenge for the clinician is to distinguish between the child with
Dr Jon Couriel, self-limiting or minor problems and the child with serious, perhaps
Respiratory Unit, Royal progressive, lung disease. To do this, it is necessary to assess the severity
Liverpool Children’s
and to diagnose the cause of the symptoms. This depends very much on
Hospital, Eaton Road,
West Derby, Liverpool
taking a detailed history, on detecting any abnormal physical signs, and
L12 2AP, UK in selected cases, on the use of appropriate investigations. There needs
British Medical Bulletin 2002;61: 115–132  The British Council 2002

Childhood respiratory diseases
Table 1 Causes of recurrent or persistent cough
Asthma Very common

Recurrent ‘normal’ infections Very common
Prolonged infection (e.g. pertussis, mycoplasma, RSV) Common

Cigarette smoking (passive/active) Common
Habit or psychogenic cough Common

Idiopathic Common
Aspiration Uncommon
Gastro-oesophageal reflux Uncommon
Incoordinate swallowing Uncommon
Intrabronchial foreign body Uncommon
Mediastinal or pulmonary tumours Very rare
Suppurative lung disease All uncommon

Cystic fibrosis
Post-infective (e.g. adenovirus, pertussis)
Tuberculosis
Ciliary abnormalities
Congenital abnormalities of the respiratory tract
Retained foreign body
Immunodeficiency
to be a high index of suspicion about uncommon disorders, such as immuno-

deficiencies, ciliary abnormalities, or congenital anomalies of the respiratory
tract. My aim is to describe how these children should be assessed.
Incidence of respiratory infections in children

Acute respiratory infections are the commonest illnesses of childhood. In
Britain, they account for a third of all consultations between GPs and
children and 8–18% of acute hospital admissions1,2. Most involve only
the upper respiratory tract, but in 10–30% the lower respiratory tract is
also affected. It is common for children to have 6–10 upper respiratory
tract infections (URTIs) in a year3,4. The peak incidence is at 6–12
months of age, with an increase when the child first mixes with large
numbers of children at nursery or school.
Most respiratory infections are mild, self-limiting and caused by viruses.
The commonest viral pathogens are rhinoviruses, coronaviruses, the
respiratory syncytial virus (RSV), influenza and parainfluenza, and adeno-
viruses. Streptococcus pneumoniae (pneumococcus) and other streptococci,
Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydia
pneumoniae and Moraxella catarrhalis are the commonest non-viral
pathogens for lower respiratory infections3,5. Co-infection with more than
116 British Medical Bulletin 2002;61

The child with recurrent chest infections
one type of bacteria or virus is present in 8–30% of pneumonia3,5. In

many cases, no pathogen can be identified.
The incidence of lower respiratory tract infections (LRTIs) such as
pneumonia, bronchiolitis and bronchitis has been assessed in prospective
studies5,6. Wright showed a cumulative incidence of acute LRTIs of 33% in
the first year of life in a birth cohort of 1179 infants in Tucson7. RSV was

the commonest of the 12 pathogens identified and acute bronchiolitis
accounted for 60% of episodes. Murphy, in an 11 year community-based
study, showed a peak incidence for LRTIs at the end of the first year of life:
a quarter of these LRTIs were pneumonia8. Jokinen found an incidence of
radiologically proven pneumonia of 36 per 1000 children per year below
the age of 5 years, and 16 per 1000 children per year in 5–14-year-olds, in
a large Finnish study9. The overall hospitalisation rate for pneumonia was
4/1000 children/year between the ages of 1 month and 15 years, but 5 times
higher in children aged below 2 years10. No community studies have
reported the incidence of recurrent pneumonia, but 10% of over 2900
children admitted to Toronto’s Hospital for Sick Children with pneumonia
had two or more episodes11.
Factors influencing the incidence of lower respiratory infection

When assessing children who present with repeated chest infections, it is
important to recognise the factors that affect the incidence of these
infections in children (Table 2)3.
The child’s age influences the type and frequency of all respiratory
infections. The normal fall in the incidence of LRTIs with age reflects the
pattern of exposure to infection and the development of the child’s
immunity. Some infections occur only in children within a specific age band.
For example, acute bronchiolitis occurs almost exclusively in infants aged
1–8 months, although many affected children have recurrent cough, wheeze
and breathlessness for months or years afterwards. Age also affects severity
and two-thirds of childhood deaths due to respiratory infections occur in
infancy3. Lower respiratory infections are more common in boys than girls,
for reasons that are not understood.
Table 2 Risk factors for lower respiratory infections in children
Age
Male sex
Prematurity
Parental smoking
Large family size, overcrowding
Congenital abnormalities
Immunodeficiency
British Medical Bulletin 2002;61 117

Infants born prematurely, and particularly those who develop broncho-

pulmonary dysplasia (chronic lung disease of prematurity) after ventilation,
frequently require hospital admission for respiratory infections in early
childhood. The mortality from infection in these infants is higher than in
term infants.
The immunoprotective effect of breast feeding against respiratory

infections is most important in non-industrialised countries, but is also
evident in industrialised societies12.
Parental smoking increases the risk of all respiratory illnesses and
symptoms, and particularly lower respiratory tract infection, in children13,14.
The effect is greater in infants than in older children, is related more to
maternal than paternal smoking, and is dose-related. Both maternal
smoking during pregnancy and postnatal passive exposure predispose the
children of smokers to recurrent respiratory infections and symptoms14.
Exposure to other children influences the number of infections children
develop. Infants with older siblings or from over-crowded homes, have
more frequent respiratory infections. When children first attend school or
nursery, the number of infections they contract rises.
Children with congenital defects of the respiratory tract, such as tracheo-
oesophageal fistula or sequestration, and children with congenital heart
disease, are at increased risk of recurrent respiratory infection. Neuro-
logically handicapped children are particularly vulnerable. Recurrent or
persistent chest infections are a common presenting feature of cystic fibrosis,
the commonest cause of bronchiectasis in children. Infections in all of these
groups of children are not only more common but also more severe than in
normal children, with a greater risk of respiratory failure and death.
Some children with recurrent or persistent chest infections have a defect
in the complex system of defence mechanisms which normally protect the
lungs from a hostile microbiological environment. These include physical
Table 3 Lung defence mechanisms
Physical and physiological defences Secretory defences

Airway filtration of particles Immunoglobulins G, A, M and E
Cough Collectins
Sneezing α1–Antitrypsin and α2-macroglobulin
Bronchoconstriction Lysozyme
Mucociliary clearance Lactoferrin
Airway mucus Complement
Respiratory cilia α and β Defensins
Alveolar fluid movement Interferon
Cellular defences
Lymphocytes (T- and B-cells)
Pulmonary macrophages
Neutrophils

defences such as cough and mucociliary clearance, circulating and resident

cellular defences, and a range of humoral or secretory mechanisms (Table
3). Collectively, their function is to prevent the entry or to remove foreign
material from the lung. Detailed accounts of the organisation and properties
of these defences are given elsewhere in this issue and in review articles15–18.

Differential diagnosis of recurrent chest infections
Most children referred with recurrent respiratory infections have normal
immune and other respiratory defences. They are simply at one end of the
normal distribution of acute respiratory infections, often because of their
age or environment. Rubin19 has described these children as ‘normal but
unlucky’. Characteristically, they are growing and developing normally, the
examination and chest X-ray are normal between episodes, there is no
family history of severe infections, and no serious extrapulmonary
infections. Reassurance is all that is required.
Asthma
Despite recent advances in care, many children referred with ‘recurrent
chest infections’ or a ‘persistent cough’ will be shown to have
undiagnosed asthma. Closer attention to the history reveals that most,
but not all, have recurrent episodes of cough, wheeze and breathlessness,
often with the characteristic trigger factors of URTIs, exercise, cold air,
emotional upset, or exposure to pets and other aero-allergens. There is
often a personal or family history of other atopic conditions such as
eczema or allergic rhinitis. They may have responded to bronchodilators
or anti-inflammatory therapy. Examination is often normal at the time
of consultation, but spirometry may indicate airways narrowing and
bronchodilator responsiveness. There is no agreed clinical definition or
pathognomic test for childhood asthma and making the diagnosis can be
difficult, particularly in children below the age of 3 years20. Further-
more, in some children, asthma co-exists with another disorder, such as
a specific antibody deficiency. Signs which suggest an alternative or
additional diagnosis include asymmetric or focal chest signs, finger
clubbing, failure to thrive or the features of systemic disease. A cough
productive of purulent sputum is not a feature of asthma.
Post-infective cough
Some parents clearly describe a cough which first appeared with an

acute infection and which has persisted for weeks or months since. This

is common after Bordetella pertussis (whooping cough) and M.

pneumoniae infections3. With these pathogens the cough, which may be
paroxysmal, may yield clear or white mucus. It is the result of the
bronchial hyper-reactivity and impaired mucociliary clearance that
follow the inflammation that occurs with these infections. The cough
normally subsides within 2–6 months. Episodes of wheeze, cough and

breathlessness, which may recur for months or years, are common in
infants who have been admitted to hospital with RSV bronchiolitis21,22.
The pathophysiology of this ‘post-bronchiolitis syndrome’ is complex,
involving abnormalities of both immune function and airway growth.
Inhaled foreign body
The possibility of an inhaled foreign body should be considered in any

young child who develops a persistent productive cough, particularly if
there has been an acute onset after an episode of choking. Some
intrabronchial foreign bodies, notably peanuts, evoke severe inflam-
mation of the bronchial mucosa which quickly leads to airways
obstruction and distal infection. Even after the diagnosis of a foreign
body has been made and it has been removed bronchoscopically, there
may be persistent localised airway damage, abnormal lung function and
a persistent cough23.
Chronic suppurative lung disease

In a minority of children who present with recurrent chest infections, the
cardinal symptom is a persistent or recurrent loose cough that is
productive of yellow or green sputum. This suggests chronic suppurative
lung disease (Table 1) and possibly bronchiectasis, which is defined as
cylindrical or saccular dilatation of the subsegmental bronchi. The
incidence of these conditions is unknown24. Some children with chronic
suppurative lung disease present with recurrent or persistent pneumonia:
while any normal child can have one episode of pneumonia, recurrent or
poorly resolving episodes often indicate an underlying abnormality.
Some of these children will also have recurrent ear or sinus infections.
Wheeze and chest pain are present in over a fifth of children with
bronchiectasis24. As the differential diagnosis includes several inherited
conditions (for example, cystic fibrosis, ciliary dyskinesia and some
immunodeficiencies), it is important to take a detailed family history of
severe or recurrent respiratory or systemic infections in childhood. As
certain acute infections, such as adenoviral pneumonia, can lead to
bronchiectasis, it is vital to obtain a detailed history of the first episode

of symptoms. A history of swallowing difficulties or choking with feeds,

or of gastro-oesophageal reflux, should be sought as recurrent
aspiration of feeds is an important cause of recurrent pneumonia11 and
chronic suppurative lung disease, particularly in children with neuro-
developmental problems25,26. The acute onset of symptoms after an
episode of choking is highly suggestive of an inhaled foreign body in

young children.
The clinical examination may reveal important signs such as wheeze,
crackles, hyperinflation, finger clubbing, hepatosplenomegaly, nasal
disease, skin lesions and failure to thrive. A plain chest X-ray may show
either focal or wide-spread changes such as atelectasis, hyperinflation,
consolidation or abnormal patterns of the airways. The left lower,
lingula and right middle lobes are the most commonly affected24.
Cystic fibrosis
Cystic fibrosis is the commonest cause of chronic suppurative lung

disease in children, affecting one in 2500 births in Caucasians. Most
affected children present with recurrent chest infections in early
childhood and over 90% also have malabsorption and failure to thrive
due to pancreatic insufficiency. About 10–20% present with neonatal
intestinal obstruction due to meconium ileus. Others are diagnosed
because of a family history of this autosomal recessive condition or by
neonatal screening.
Viscid mucus in the small airways predisposes to chronic infection,
initially with Staphylococcus aureus or H. influenzae, but later with
Pseudomonas aeruginosa (see elsewhere in this issue). The infection, and
the inflammatory response to it, lead to progressive damage of the
bronchial wall, bronchiectasis, cystic lesions and eventually lung
fibrosis. Cystic fibrosis must always be considered early in the differ-
ential diagnosis of recurrent chest infections.
Bronchiectasis following acute pneumonia
In the past, many cases of childhood bronchiectasis followed acute

lower respiratory tract infections with pertussis, measles or tuberculosis.
This is now rare. Virtually all children with normal immune function
will make a full recovery from pneumonia or bronchiolitis, even if the
acute episode was severe. However, there are important exceptions to
this rule. Adenovirus serotypes 3, 4, 7, and 21 can all cause severe
bronchiolitis, pneumonia and death27,28. Up to 40–70% of survivors are
left with permanent damage to the airways (bronchiolitis obliterans)

with segmental or lobar atelectasis, areas of hyperinflation and impaired

lung function29. A quarter of children with bronchiolitis obliterans sub-
sequently develop bronchiectasis30. Typically, these children are left with
persistent wheeze (which responds poorly to bronchodilators), a persistent
cough (which is initially dry but then becomes productive of purulent
sputum), and the characteristic radiological changes of bronchiolitis

obliterans. Swyer-James or MacLoed’s syndrome, where there is a small
hyperlucent lobe with impaired perfusion and ventilation, has also been
described after these infections. Similar damage can follow severe myco-
plasmal pneumonia. Co-infection with both adenovirus and M. pneumoniae
is particularly devastating.
Although most children make a full recovery from bacterial pneumonia,
in some there is slow or incomplete resolution, with persisting localised
clinical signs and atelectasis or inflammation on the chest X-ray. This may
be due to obstruction of a bronchus by a plug of mucopus or localised
damage to the bronchus and the adjacent lung parenchyma, but in some
cases it reflects an underlying abnormality of the lung anatomy or defences
or an inhaled foreign body. The cough continues and may become
productive of sputum: there may be exacerbations with fever. These
children need detailed assessment.
Immunodeficiency disorders
The respiratory tract is the organ system most commonly involved in

immunodeficiency disorders. There is often a delay of years between the
onset of symptoms and the diagnosis being made: this delay increases
the risk of bronchiectasis and irreversible lung damage occurring before
appropriate treatment is given31.
An immune defect should be considered in any child who has respiratory
infections that are unusually severe, recurrent, unresponsive to
conventional treatment, or atypical. Common associated features include
failure to thrive, which is often secondary to gastrointestinal disease, severe
atopic disease such as eczema, and occasionally, auto-immune disease4,31,32.
Some children with certain syndromes, such as DiGeorge and Down’s
syndromes, have abnormalities of their immunity as well as cardiac, facial
and other anomalies. As many immunodeficiencies are inherited, a family
history of severe infection or early death or consanguinity should be
sought. As well as respiratory infections, there may be severe infections of
the skin, gastrointestinal tract and soft tissues, and lymphadenopathy. The
clinical examination is often abnormal in children with immunodeficiency.
Immunodeficiencies are classified as primary (congenital) or secondary
(acquired). In the past, secondary immunodeficiencies were most often
the result of disorders such as malignancy, immunosuppressive therapy,

measles, or malnutrition, but in many countries HIV infection is now the

commonest cause of acquired immunodeficiency.
Over 80 different primary immunodeficiencies have been identified.
These can be classified on the basis of which of the four sections of ‘the
immune orchestra’ (antibodies, T-lymphocytes, phagocytes or the com-
plement system) is involved, but disorders in which there are

abnormalities in more than one section are common. For example, in the
severe combined immunodeficiencies (SCID), which are the most severe
disorders, there are defects in both cell-mediated (T-lymphocyte) and
antibody (B-lymphocyte) function. Defects of humoral (antibody)
immunity account for 50% of primary immunodeficiencies, combined
humoral and cellular deficiencies constitute 20–30% of cases, phagocyte
defects approximately 18% and complement defects less than 2%31.
As one would expect, the younger the child when infections first appear, the
more severe the immune defect is likely to be. Most defects involving cell-
mediated immunity present within the first 6 months of life, frequently with
the triad of pneumonia, intractable diarrhoea and mucocutaneous
candidiasis31. Antibody deficiencies such as X-linked agamma-globulinaemia
(XLA), often cause recurrent respiratory infections between the ages of 4
months – when levels of maternally derived IgG have fallen – and 2 years of
age, but there is often a delay of 2–5 years before the diagnosis is made31.
Phagocyte and the rare complement defects can also present at this stage.
Common variable immunodeficiency, a heterogeneous group of disorders
with hypogammaglobulinaemia and defective antibody production, usually
presents after the age of 5 years, often in the second or third decade of life.
Table 4 lists the major categories of immunodeficiency and gives some
examples of disorders within each category that can present with severe,
recurrent, persistent or unusual chest infections. As the nature of the
immune defect determines the susceptibility to particular micro-
organisms, identifying the pathogen is not only important in deciding
what treatment is appropriate, but it may also indicate which part of the
immune system is defective. For example, identification of Pneumocystis
carinii and cytomegalus virus (CMV) in bronchial lavage fluid from a
child with interstitial pneumonia would suggest a defect of T-cell
function, whilst recurrent cavitating staphylococcal pneumonia, which
is refractory to appropriate antibiotics suggests a neutrophil defect, such
as chronic granulomatous disease.
Defects of antibody production

Antibody deficiencies are the commonest of immunodeficiencies33. There
are many different types of antibody deficiency, ranging from severe
deficiencies of all immunoglobulins (X-linked agammaglobulinaemia,
Bruton’s disease) to milder deficiencies of specific antibodies in children
with normal immunoglobulin levels. They may occur as an isolated

Table 4 Classification of primary immunodeficiencies
Immunodeficiency and examples Major pathogens in this group Investigations
ANTIBODY (B-CELL) DEFICIENCY

X-linked agammaglobulinaemia (XLA) H. influenzae Immunoglobulins (G, A, M, E)
IgA, IgG subclass deficiency Strep. pneumoniae IgG subclasses
Specific antibody deficiency Giardia lamblia Specific antibodies

Common variable immunodeficiency ECHO virus B-cell populations
Salmonella spp.
M. pneumoniae
DEFECTIVE CELLULAR IMMUNITY (T cell deficiency)

and SEVERE COMBINED IMMUNODEFICIENCIES (SCID)
Adenosine deaminase (ADA) deficiency Herpes simplex, zoster White cell differential
Hyper IgM syndrome CMV, EBV, measles, RSV Chest X-ray (thymic shadow)
Major histocompatibility complex deficiency Pn. carinii Lymphocyte populations
Wiskott-Aldrich syndrome Streptococci, H. influenzae Mitogen responses
Candida, Aspergillus
Mycobacteria (typical and atypical)
Cryptosporidium
PHAGOCYTE DEFECTS
Chronic granulomatous disease (CGD) Staph. aureus White cell differential
Familial, cyclical or auto-immune neutropenia Streptococci Chemotaxis, phagocytosis
Leukocyte adhesion defects Candida, Aspergillus Nitroblue tetrazolium test
Hyper IgE syndrome (Job’s syndrome) Enteric Gram-negative bacteria
COMPLEMENT DEFICIENCY
Mannose-binding protein Strep. pneumoniae, H. influenzae C3, C4, CH 50 levels
C3 or C5 deficiency Neisseria meningitidis
This is not an exhaustive or complete classification. The investigations are for disorders of that component of the immune system and
not the specific disorders.
defect or as part of a wider immunodeficiency. It is not possible to give

a comprehensive review of all of these defects and only some of the
commonest types which present with chest problems in children are
described here.
The normal term infant has undetectable serum levels of IgM and IgA at
birth and these rise progressively in the first 2–3 years of life32,33. The
maternal IgG which crosses the placenta into the fetus disappears within
5–7 months. The infant’s own IgG appears at significant levels at 4–8
months and rises for 2–3 years. Anti-protein antibodies are produced in the
first few months of life, but the ability to produce IgG antibodies against
polysaccharide antigens, such as the capsules of certain bacteria, matures
much more slowly and is only effective after 2 years. IgG has four sub-
classes (1–4) which differ in concentration, structure and function.
Antibodies against protein are mainly of the IgG1 and IgG3 subclasses and
those against polysaccharides are predominantly of the IgG2 subclass.

It is now recognised that many children with recurrent chest infections

have abnormalities in their ability to produce specific antibodies to
common respiratory pathogens such as the Strep. pneumoniae or H.
influenzae which is commonly isolated from their sputum. Many of these
children are diagnosed as suffering from asthma and are receiving high
doses of inhaled steroids and other asthma therapies. Important clues to

the diagnosis include the lack of response to high doses of asthma
treatment, the presence of a productive cough and coloured sputum, and
improvement with courses of antibiotics. There may be a history of
recurrent upper respiratory infections, such as otitis media or tonsillitis. If
an antibody deficiency is suspected, total serum levels of IgG, IgM, IgA and
IgE should be measured. As the normal ranges of these proteins change
during childhood, the measured values must be compared to the age-
appropriate normal values, ideally from the same laboratory. There is
controversy about the value of also measuring IgG sub-class levels as not
all children with ‘deficient’ sub-classes have evidence of an increased
susceptibility to infection34. Nevertheless, IgG subclass deficiency, and
particularly IgG2 deficiency, can be associated with severe bronchiectasis
and many clinicians still measure IgG subclasses.
It is important to measure serum levels of specific antibodies against
protein antigens (tetanus and diphtheria toxoids) and polysaccharide
antigens (H. influenzae type b [Hib] and Strep. pneumoniae). A key
element of the evaluation of humoral immunity is the assessment of the
child’s ability to produce normal levels of specific antibodies in response
to the routine childhood immunisations or 4 weeks after test vaccin-
ations with Hib and polyvalent pneumococcal vaccines (Pneumovax®).
Care is needed in the interpretation of these tests as the child’s age
profoundly influences the response to these immunisations. For
example, a persistently low level of anti-pneumococcal antibodies after
Pneumovax® in a 10-year-old suggests a pathological defect in antibody
production, whereas low levels and the lack of a response in a 2–3-year-
old is normal and simply indicate physiological immaturity. It is difficult
to make a definite diagnosis of a specific anti-pneumococcal antibody
deficiency in a child aged less than 5–6 years.
Selective IgA deficiency is the commonest immunodeficiency with an
incidence of 1:400–70032,33. Many affected individuals are asymptomatic,
but others, and particularly those who have an associated IgG subclass or
specific antibody deficiency, suffer from recurrent sinopulmonary
infections. As serum IgA levels are low in healthy children and do not reach
adult levels until the age of 8 or 9 years, a diagnosis of IgA deficiency
should not be made in children below the age of 4 years33.
In another important antibody deficiency, X-linked agammaglobulin-
aemia, there are low or undetectable levels of all the major immuno-
globulins due to abnormalities of the BTK gene and B-cell differentiation in

affected boys. There may be an associated neutropenia. Pyogenic infections

such as pneumonia first appear after 6–12 months. Unless treated with
regular intravenous or subcutaneous immunoglobulin therapy and aggressive
antibiotic treatment of acute infections, this progresses rapidly to chronic
bacterial bronchitis and irreversible lung damage with bronchiectasis.

T-cell deficiencies
T-lymphocytes are essential not only in controlling viral, fungal, myco-
bacterial and protozoal infections, but also in aiding B-cells to produce
immunoglobulins33. Children with T-cell deficiencies can present with
severe bacterial infections as well as the classic opportunistic infections.
Primary T-cell deficiencies are rare inherited disorders. Children with
severe combined immunodeficiency (SCID) have profoundly defective T-
cell and B-cell function. Although they can present with recurrent chest
infections, these are often associated with other severe acute infections,
including septicaemia, severe and refractory mucocutaneous fungal
infections and enteropathies35. Most untreated children die in infancy and
the only cure is bone marrow or stem-cell transplantation.
Many children with DiGeorge syndrome, in which there is a micro-
deletion of chromosome 22q11.2, have a milder T-cell deficiency, with
reduced lymphocyte and T-cell numbers and poor in vitro T-cell pro-
liferation responses to mitogens such as phytohaemogluttinin or poke
weed mitogen. These defects often improve as the child grows older, but
affected children may have recurrent chest infections and bronchiectasis
in early childhood.
Phagocyte disorders
Primary disorders of phagocyte numbers or function are relatively
uncommon in children36. Recurrent sinopulmonary, gastrointestinal and
soft tissue infections due to Staph. aureus, Burkholderia cepacia, Serratia
marcascens and fungi are the usual mode of presentation. In boys with
chronic granulomatous disease (CGD), the commonest serious phagocytic
disorder, in which there is defective killing of ingested micro-organisms,
cavitating pneumonia which responds poorly to antibiotic therapy is a
common presentation. Severe pneumonias, empyemas and bronchiectasis
are common in children with the hyper-IgE (Job) syndrome, who have a
wide variety of defects of neutrophil, lymphocyte and humoral function as
well as very high levels of serum IgE37.
Disorders of ciliary function
In healthy children, the microcilia of the respiratory epithelium beat in a

regular co-ordinated manner, propelling mucus proximally to the

oropharynx where it is swallowed or expectorated. The mucus provides

both a physical and a chemical barrier to pathogens15,38.
The estimated prevalence of primary ciliary dyskinesia (PCD) is
1:16,000–20,00038. Recent developments in high speed digital imaging
have led to the identification of an increasing number of congenital
defects of ciliary structure, beat pattern and frequency when used in

conjunction with electron microscopy studies of nasal epithelial brush
biopsies15. Many cases of PCD are undiagnosed38 reflecting poor
awareness of the spectrum of the clinical patterns of these disorders and
the difficulty in making an accurate diagnosis. Most cases are autosomal
recessive, but other patterns of inheritance have been reported – the
affected genes have not yet been identified. Males and females are
equally affected.
Children with primary ciliary dyskinesia have abnormal mucociliary
clearance. PCD may present in new-born infants with tachypnoea or
pneumonia, sometimes associated with nasal obstruction and a
mucopurulent discharge. In the older infant and child, it typically
presents with a persistent productive cough, atypical asthma, or
occasionally severe gastro-oesophageal reflux, and later with the
features of bronchiectasis. As the upper respiratory tract is also affected,
chronic purulent rhinitis, sinusitis, and chronic secretory otitis media
with effusion and conductive deafness are often also present38. Half of
children with classical Kartagener’s syndrome have situs inversus and
dextrocardia in addition to these features and there is an increased incidence
of congenital heart disease, hydrocephalus and oesophageal atresia. Most
affected males are infertile because of immotile spermatozoa and affected
women can be subfertile.
Making the diagnosis of primary ciliary dyskinesia is technically
difficult. It depends on the assessment on ciliary structure and function
using the specialised techniques mentioned above and few centres have
the ability to produce reliable results. False negatives and false positives
do occur. Abnormal ciliary function is also seen in asthma, cystic fibrosis
and after certain viral and bacterial infections (secondary ciliary
dyskinesia). Traditional tests of mucociliary clearance, such as the
saccharin test, are not reliable in children. Nasal nitric oxide is lower in
children with PCD than in healthy controls or children with asthma and
other forms of bronchiectasis and this may prove to be a useful screening
test for this group of conditions in the future39.
Congenital abnormalities of the lung
Recurrent or persistent chest infections are common in children with

congenital abnormalities of the airways, lung parenchyma and pulmonary

vasculature39,41. For example, repeated episodes of pneumonia are often the

presenting feature of lobar sequestration, bronchial stenosis and broncho-
malacia, and cystic adenomatoid malformations of the lung42. Such an
abnormality should be suspected if one lobe is repeatedly infected or if
there is incomplete resolution after treatment. Computerised tomography
and magnetic resonance scanning are helpful in defining the anomaly prior

to surgical excision.
Children born with oesophageal atresia and tracheo-oesophageal fistula
often have repeated episodes of pneumonia and bronchitis in early life as a
result of persisting abnormalities of airway and oesophageal function43.
The condition has an incidence of 1:3000 and associated vertebral, anal,
cardiac, renal or limb defects (VACTERL anomalies) are seen in up to 50%
of affected children42. In one series of 334 survivors of tracheo-oesophageal
fistula with oesophageal atresia, 31% had had one or more episodes of
pneumonia in the first 5 years of life and 5% had been admitted on more
than 5 occasions. Many more had recurrent ‘bronchitis’ in childhood44.
The rates of pneumonia and bronchitis fall as the children grow older.
Gastro-oesophageal reflux, oesophageal dysmotility and strictures all
predispose to recurrent aspiration pneumonia in these children. Some
require further oesophageal surgery to prevent progressive lung damage
and to allow adequate nutrition. Both restrictive and obstructive patterns
of lung dysfunction are present in 18–60% of survivors43,45.
Tuberculosis
Tuberculosis should be considered in any child with a persistent
productive cough, particularly if there are systemic features such as
fever, weight loss or general malaise. Since most tuberculous infections
are transmitted by inhalation, primary lesions occur in the lungs in over
95% of infected children. As with adults, there are several different
clinical and radiological patterns of lung disease that can develop from
the primary complex. These include effusions, cavitation, bronchial
obstruction due to mediastinal lymphadenopathy with atelectasis or
distal emphysema, tuberculous pneumonia, endobronchial tuberculosis,
or miliary disease. Post-tuberculous bronchiectasis is rare nowadays.
Extrapulmonary manifestations, of which meningitis is the most serious,
are more common in children than in adults. The diagnosis depends on
a high index of suspicion, tuberculin skin testing, radiology, and micro-
biology of sputum and gastric washings.
Investigation of the child with chronic suppurative lung disease
It is impossible to overemphasise the importance of the clinical history

and examination in the assessment of these children.

The plain chest X-ray is valuable in assessing the severity and distribution
of lung involvement. Wide-spread changes such as bronchial wall
thickening or inflammation involving several lobes suggests a systemic
disorder such as cystic fibrosis, ciliary dyskinesia or an immunodeficiency
disorder. Focal changes are more common if there is a congenital
abnormality, an inhaled foreign body or bronchial obstruction for some

other reason. High resolution computerised tomography (HRCT) is more
sensitive than plain radiographs at revealing bronchiectasis: it has largely
replaced bronchography. It can also show localised areas of gas-trapping
(hyperinflation) and interstitial fibrosis not evident on the chest X-ray, for
example in children with bronchiolitis obliterans. CT scanning and
magnetic resonance imaging are both helpful for assessing congenital
anatomical abnormalities, such as sequestration or cystic adenomatoid mal-
formations. Isotope scans provide useful evidence about regional ventilation
and perfusion.
All children with persistent cough should have their sweat electrolytes
measured. The sweat test remains the standard diagnostic test for CF,
although CF gene mutation studies are being used increasingly. Other
investigations include bacteriological studies on sputum if this can be
produced; viral and mycoplasmal antibody levels; tuberculin skin
testing; and in selected cases, immune function tests. All children should
a full blood count and white cell differential: persistent lymphopenia or
neutropenia may be present even when the child is well.
Which immune tests are performed will depend on the nature and severity
of the respiratory symptoms. For example, in the child who has repeated
episodes of cough with purulent sputum containing Strep. pneumoniae or H.
influenzae, but who is otherwise well with no clinical or radiological evidence
of lung damage, measurement of immunoglobulin and immunoglobulin
subclass levels, and specific antibody levels against pneumococcus, tetanus
and Hib would be appropriate, as a specific antibody deficiency is the most
likely diagnosis. Children with low Hib and anti-pneumococcal antibody
levels should be immunised with Hib vaccine and (over the age of 4 years)
Pneumovax® and have their antibody levels repeated 4–6 weeks later. By
contrast, a child with severe opportunistic pneumonia demands a detailed
assessment of cellular and humoral immune function (Table 4). This should
be planned with a clinical immunologist.
Flexible fibre-optic bronchoscopy is now established as a key investi-
gation in the assessment of children with chronic lung sepsis or suspected
immunodeficiency. Microbiological and cellular specimens can be obtained
by suction, by the use of a protected brush, or by broncho-alveolar lavage.
Bronchoscopy also allows a detailed evaluation of the tracheobronchial
anatomy and dynamics and identification of unsuspected foreign bodies.
If recurrent aspiration is suggested by the history, this may be detected by
isotope milk scans. Incoordinate swallowing, which is most commonly

seen in children with severe neurodevelopmental problems, such as

cerebral palsy or severe myopathies, should be assessed by video fluoro-
scopic barium swallow26. Although oesophageal pH monitoring can give
both false positive and false negative results, it remains the best test for
assessing the frequency and severity of gastro-oesophageal reflux.
Respiratory ciliary studies require referral to a specialist centre.

Organisation of care
The assessment and management of children with chronic suppurative
lung disease or recurrent severe infection is complex. It requires the
involvement of several disciplines, including respiratory paediatricians,
paediatric radiologists, immunologists, physiotherapists and micro-
biologists. The multidisciplinary team approach that has been so successful
in improving the care and prognosis of people with cystic fibrosis is now
being adopted for the care of this demanding group of patients in some
specialist paediatric centres, including the Royal Liverpool Children’s
Hospital. Concentrating the experience of many rare conditions within a
specialised team allows the development of a more methodical approach to
the clinical care of these children. It also has the potential for the clinical
research that is clearly required to establish the optimal care of these
children.
Key points for clinical practice

• There are many different causes of recurrent chest infections in children. The
clinician has to distinguish between children with self-limiting or easily
managed conditions, such as recurrent acute viral infections or asthma and
those with more severe, often progressive, diseases
• It is important to understand the epidemiology of acute respiratory infections in
children and the factors that influence the pattern of these common infections
• A chronic or recurrent cough productive of purulent sputum, or repeated
episodes of pneumonia, suggest chronic suppurative lung disease and the
possibility of bronchiectasis. These children require detailed and specialist
assessment
• The commonest causes of suppurative lung disease are cystic fibrosis, immune
deficiencies, congenital lung and ciliary abnormalities, and lung damage caused
by acute pneumonia. Other causes include an unsuspected foreign body or
recurrent aspiration
• Although a meticulous history and examination are vital in assessing these
children, specialist investigations including sweat tests, immune and ciliary

function tests, and bronchoscopy are often indicated. Plain radiology, CT and
MR scanning can all help define the site and severity of any abnormalities such
as bronchiectasis, atelectasis or congenital anomalies. A multidisciplinary team
approach to the assessment and care of this demanding and complex group of
children has many advantages

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Assesment of Recurrent Chest Infections

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Assessment of the child with recurrent chest

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Recurrent chest infections are a common reason for children to be seen

British Medical Bulletin 2002;61: 115–132  The British Council 2002

Table 1 Causes of recurrent or persistent cough

Asthma Very common

Prolonged infection (e.g. pertussis, mycoplasma, RSV) Common

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Suppurative lung disease All uncommon

to be a high index of suspicion about uncommon disorders, such as immuno-

Incidence of respiratory infections in children

116 British Medical Bulletin 2002;61

one type of bacteria or virus is present in 8–30% of pneumonia3,5. In

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Factors influencing the incidence of lower respiratory infection

Table 2 Risk factors for lower respiratory infections in children

British Medical Bulletin 2002;61 117

Infants born prematurely, and particularly those who develop broncho-

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Table 3 Lung defence mechanisms

Physical and physiological defences Secretory defences

118 British Medical Bulletin 2002;61

defences such as cough and mucociliary clearance, circulating and resident

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Some parents clearly describe a cough which first appeared with an

British Medical Bulletin 2002;61 119

is common after Bordetella pertussis (whooping cough) and M.

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Inhaled foreign body

The possibility of an inhaled foreign body should be considered in any

Chronic suppurative lung disease

120 British Medical Bulletin 2002;61

of symptoms. A history of swallowing difficulties or choking with feeds,

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Cystic fibrosis is the commonest cause of chronic suppurative lung

Bronchiectasis following acute pneumonia

In the past, many cases of childhood bronchiectasis followed acute

British Medical Bulletin 2002;61 121

with segmental or lobar atelectasis, areas of hyperinflation and impaired

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The respiratory tract is the organ system most commonly involved in

122 British Medical Bulletin 2002;61

measles, or malnutrition, but in many countries HIV infection is now the

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Defects of antibody production

British Medical Bulletin 2002;61 123

Table 4 Classification of primary immunodeficiencies

Immunodeficiency and examples Major pathogens in this group Investigations

ANTIBODY (B-CELL) DEFICIENCY

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DEFECTIVE CELLULAR IMMUNITY (T cell deficiency)

defect or as part of a wider immunodeficiency. It is not possible to give

124 British Medical Bulletin 2002;61

It is now recognised that many children with recurrent chest infections

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British Medical Bulletin 2002;61 125

affected boys. There may be an associated neutropenia. Pyogenic infections

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Disorders of ciliary function

In healthy children, the microcilia of the respiratory epithelium beat in a

126 British Medical Bulletin 2002;61

oropharynx where it is swallowed or expectorated. The mucus provides

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